eMedicine Specialties > Orthopedic Surgery > Neoplasms

Postradiation Sarcoma: Treatment & Medication

Author: Nagarjun Rao, MD, FRCPath, Assistant Professor, Department of Pathology, Medical College of Wisconsin
Coauthor(s): Donald A Hackbarth Jr, MD, FACS, Professor of Clinical Orthopedic Surgery, Division Chief, Musculoskeletal Oncology, Department of Orthopedic Surgery, Medical College of Wisconsin; Stuart Wong, MD, Assistant Professor, Department of Medicine, Section of Hematology/Oncology, Froedert Memorial Lutheran Hospital; Vivek Panikkar, MBBS, MS, MCh, FRCS, Consulting Surgeon, Departments of Trauma and Orthopedics, Doncaster Royal Infirmary, UK; Vinod B Shidham, MD, FRCPath, FIAC,, Professor, Director of Cytopathology Fellowship Training Program, FNAB Service, and International Cytopathology Fellowship, Department of Pathology, Medical College of Wisconsin; Co-Editor-in-Chief and Executive Editor, CytoJournal
Contributor Information and Disclosures

Updated: Jul 14, 2009

Treatment

Medical Care

Postradiation sarcoma (PRS) ideally is managed with a multidisciplinary approach with input from the radiation oncologist, medical oncologist, and surgeon. Because PRS is high grade and advanced stage or metastatic at the time of diagnosis, patients commonly are not eligible for curative surgery, and the prognosis for these patients generally is poor. Chemotherapy is the most common treatment modality and typically is associated with poor response rates.

Surgical Care

Surgical options for postradiation sarcoma (PRS) include wide or radical resection (limb salvage) or amputation, and depend upon the stage and location of the tumor and the age and performance status of the patient. In patients with peripherally located tumors at stage IIB and below (MSTS system), it is feasible to expect resection to provide a reasonable 5-year survival rate. (In one study, the 5-year survival rate for this group approached 68%.) Brachytherapy or postoperative external beam radiation can be added if the margins are close to the tumor.

Consultations

A multidisciplinary approach is ideal for postradiation sarcoma (PRS). The surgical oncologist, who preferably has experience in treating sarcomas, should be involved at the outset for the diagnostic evaluation. In addition, input from the radiation oncologist and medical oncologist is necessary to achieve a coordinated treatment plan, particularly for patients in whom combined modality treatment is being contemplated.

Diet

Nutrition is an important aspect in the care of patients receiving active cancer treatment.¹⁹ Surgery, radiation therapy, and chemotherapy may adversely affect the patient's nutritional status and hence may alter quality of life. Cancer treatment can alter the patient's ability to eat, digest, and absorb food. Anticipation of these potential adverse effects, therefore, is necessary. Intervention, such as with commercially available liquid nutritional supplements, may be required to maintain adequate caloric intake. Consultation with a health care provider qualified in nutrition also may be considered.

Activity

The impact of physical activity upon treatment outcome in patients with cancer is not well defined in the literature. However, modest levels of physical activity during cancer treatment may provide benefits with respect to increasing appetite, maintaining mobility and muscle tone, and enhancing a sense of emotional well-being.

Medication

The selection of chemotherapy agents used to treat patients with postradiation sarcoma (PRS) is based largely upon data from clinical trials of soft-tissue and bone sarcomas. The 2 most active single chemotherapy agents are doxorubicin (Adriamycin) and ifosfamide. These agents have roughly equivalent activity. Dacarbazine (DTIC) has modest single-agent activity. MAID (combination of mesna, Adriamycin, ifosfamide, and DTIC) has been a commonly used combination chemotherapy regimen for the treatment of soft-tissue sarcoma over the past decade.

Three randomized trials have been performed in which regimens containing Adriamycin and ifosfamide were compared with Adriamycin alone. Two of these trials showed higher response rates in the treatment arms containing Adriamycin and ifosfamide than in those containing Adriamycin alone. However, the Adriamycin and ifosfamide combinations also were associated with significantly higher myelosuppression (including fatal neutropenic sepsis) but no survival advantage. No standard of care has been established for the choice of chemotherapy agents. Therefore, treatment typically is individualized.

Preoperative chemotherapy can be administered with or without radiation therapy and is administered either intravenously (as a bolus or as a continuous infusion) or regionally via an intra-arterial infusion to an isolated limb. Preoperative chemotherapy generally is considered in order to facilitate a limb-sparing procedure. This approach is considered for patients who otherwise would require amputation for cure or palliation. In some instances, this approach may be considered to convert a marginally resectable lesion into one that is operable. Consideration of preoperative chemotherapy for PRS must take into account that response rates to chemotherapy are low and that most long-term survivors with PRS are patients who have undergone successful surgical resection.

References

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Keywords

postradiation sarcoma, PRS, postirradiation sarcoma, radiation-induced sarcoma, osteosarcoma, fibrosarcoma, malignant fibrous histiocytoma, MFH, chondrosarcoma, angiosarcoma, Ewing sarcoma, malignant peripheral nerve sheath tumor, MPNST

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Contributor Information and Disclosures

Author

Nagarjun Rao, MD, FRCPath, Assistant Professor, Department of Pathology, Medical College of Wisconsin
Nagarjun Rao, MD, FRCPath is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and Royal College of Pathologists
Disclosure: Nothing to disclose.

Coauthor(s)

Donald A Hackbarth Jr, MD, FACS, Professor of Clinical Orthopedic Surgery, Division Chief, Musculoskeletal Oncology, Department of Orthopedic Surgery, Medical College of Wisconsin
Donald A Hackbarth Jr, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Tissue Banks, American College of Surgeons, Children's Oncology Group, Christian Medical & Dental Society, Clinical Orthopaedic Society, and Wisconsin Medical Society
Disclosure: Musculoskeletal Transplant Foundation Honoraria Board membership

Stuart Wong, MD, Assistant Professor, Department of Medicine, Section of Hematology/Oncology, Froedert Memorial Lutheran Hospital
Disclosure: Nothing to disclose.

Vivek Panikkar, MBBS, MS, MCh, FRCS, Consulting Surgeon, Departments of Trauma and Orthopedics, Doncaster Royal Infirmary, UK
Disclosure: Nothing to disclose.

Vinod B Shidham, MD, FRCPath, FIAC,, Professor, Director of Cytopathology Fellowship Training Program, FNAB Service, and International Cytopathology Fellowship, Department of Pathology, Medical College of Wisconsin; Co-Editor-in-Chief and Executive Editor, CytoJournal
Vinod B Shidham, MD, FRCPath, FIAC, is a member of the following medical societies: American Association for Cancer Research, American Society of Cytopathology, College of American Pathologists, International Academy of Cytology, Royal College of Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Miguel A Schmitz, MD, Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

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